Analysis of trends in SMART Nutrition Survey datafrom South Sudan between 2004 and 2016

Introduction: Emergency levels of Global Acute Malnutrition (GAM) persist in former Northern Bar el Ghazal State in South Sudan despite ongoing interventions. Reasons for long-term trends in GAM in South Sudan have not been explored despite decades of nutrition and health interventions. Objective: This project aimed to identify and analyse changes in patterns of malnutrition and key factors associated with malnutrition from 2004 to 2016.Methods: Secondary data analysis was carried out using Standardized Monitoring and Assessment of Relief and Transitions (SMART) nutrition surveys. Anthropometric data collected from children under five years of age from 2004 to 2016 were analysed to estimate seasonal differences in the prevalence of GAM (weight-for-height z-score (WHZ) <-2) and severe acute malnutrition (WHZ <-3). Risk factors for GAM were explored using data collected in 2014 and 2015 and analysed using logistic regression. Adjusted Wald tests investigated which variables were associated with GAM (p<0.05).Results: In Aweil West and North a reduction in GAM was observed between September 2004 (21.0%, CI 18.2-23.9) and November 2009 (16.2%, CI: 13.7-18.9). However, this apparent decline likely reflects a seasonal difference because the 5-year overall mean GAM was 20.4% (SD: 0.403) and 17.5% (SD: 0.380) in pre- and post-harvest seasons respectively. In multivariable linear regression modelling, not having been sick in the past two weeks (aOR 0.78, 95% CI 0.61, 0.99, p=0.047), and not having consumed juice (aOR 0.67, 95% CI 0.45, 0.99, p=0.045) were protective against GAM after adjusting for all potential confounders.Conclusion: This study highlights the impact of instability on the nutritional status of a generation, with the high prevalence of GAM and severe acute malnutrition remaining unchanged since 2004. Regular collection of representative nutrition data is useful to inform decision making. The results of this study suggest that a focus on care seeking behaviours and hygiene practices would be beneficial. The persistent prevalence of GAM identifies a need, not just for nutrition programmes but also effective prevention programmes

A North-South-South Collaborative Action to Prevent Micronutrient Deficiencies in Women and Young Children in South-East Asia: The SMILING Project.

Objectives: SMILING "Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional status and General Health in Asia" (FP7), is a transnational collaboration of research institutions and implementation agencies in five SEA countries: Cambodia, Indonesia, Laos PDR, Thailand and Vietnam, with European partners, to introduce state-of-the-art knowledge into policy to alleviate micronutrient malnutrition in SEA women of reproductive age (WRA) and young children. Objectives were to: build capacity on problem analysis; identify priority interventions and develop roadmaps for national policies. Methods: SMILING has been built around a consortium that worked on Optifood software to identify nutrient gaps; nutritional problem analysis and potential interventions by reviewing current situation and program, and knowledge on effective interventions and multi-criteria mapping for stakeholder analysis to develop national guidelines. Results: Iron, zinc, vitamin A and iodine deficiency remain common in SEA. Even though the five SEA countries differ in nutritional situation and stages of development, iron intake in young children in all countries was inadequate, as folate intake in WRA, even with theoretical best possible diets. Consequently, interventions including supplementation, food-based strategies and public health measures were appraised through multi-stakeholder analysis. Successful experiences and lessons in implementing nutrition programs in these countries were also critically reviewed. Policy roadmaps by country are being drafted accordingly. Conclusions: SMILING conducted an analysis of nutrition situation in each SEA country. Gaps in intake of several micronutrients cannot be currently solved by dietary solution and e.g. food fortification needs to be considered. Roadmaps for each country policy-makers are being formulated. Funding: European Commission-FP7, GA-2896-16.

To what Extent Can Food-based Approaches Ensure Dietary Adequacy for Women and Young Children in SE Asia.

Objectives: To predict whether food-based approaches can ensure dietary adequacy for 6-23 month old children and women of reproductive age in SE Asia and to identify problem nutrients. Methods: Linear programming was used to determine whether nutritionally adequate diets based on locally available non-fortified foods (11 micronutrients ≥ WHO/FAO RNI, assuming moderate iron and zinc bioavailability) could be formulated for women and young children in 5 countries. Model parameters were defined using nationally representative (Indonesia, Thailand, Vietnam, Cambodia) or locally representative (Laos, Cambodian children<12 months) 24-hour recall dietary data. Problem nutrients were defined as those <100% RNI in a diet where intakes were maximised. Nutrient adequacies, for food-based recommendations (FBR), were defined as those >65% RNI, when intakes were minimised, in diets achieving the FBR. Results: Numbers of problem nutrients ranged from 2-9, 1-8 and 0-5, for 6-8 mo, 9-11 mo and 12- 23 mo old children; and from 3-7, 2-4 and 1-4 for pregnant, lactating and non-pregnant- nonlactating women, respectively, depending on the country. In most countries, modeled FBRs ensured adequacy for ≥7 (children) and ≥5 (women) nutrients. In all countries, FBRs did not ensure adequate iron (all groups) and folate (women) intakes. Conclusions: Interventions, such as food fortification or the promotion of unutilized nutrient dense foods, are likely required to ensure dietary adequacy, for women and young children, in SE Asia. Funding: The European Commission, FP7, GA-2896-16.

Constraints to Attending the Maternal, Newborn and Child Health Weeks in North West Nigeria.

Objectives: This study aimed to understand the barriers to MNCHW attendance in order to develop recommendations for strengthening its social mobilization activities. Methods: In the states of Jigawa and Zamfara in northern Nigeria, 19 in-depth interviews were conducted with government officials and community leaders; and 36 focus group discussions with women with a child under 5-years of age, their husbands, town criers, health workers, community volunteers, and religious leaders on MNCHW social mobilization and barriers to attendance. Content analysis was used to derive themes. Results: Awareness of MNCHW was low among the target beneficiaries. Even where programme awareness existed, there was little understanding of the nutrition and health benefits of VAS. Social mobilization focused solely on raising awareness about the dates and location of MNCHW, it did not promote its health benefits. MNCHW has also been overshadowed by the Immunization Plus Days (IPDs) which are conducted monthly. Other barriers to MNCHW attendance included inability to afford transportation costs, and distrust of government programmes. Conclusions: To increase attendance at MNCHW in northern Nigeria, social mobilization must first address the lack of understanding of the health benefits of the MNCHW programme.

Modification of Local Diets Could Fill Gaps in B-Vitamin Intakes but Calcium, Iron, and Zinc Intake Gaps Require External Solutions for Breastfed Children in Rural Kenya.

Objectives: The objective of this study was to identify gaps in the adequacy of nutrient intakes, and food-based recommendations to fill those gaps, from complementary diets of 6-23 mo old children in two agro-ecological zones of rural Kenya. Methods: In a high rainfall area of Western Kenya (Vihiga) and a semi-arid area of Eastern Kenya (Kitui), food and nutrient intakes from complementary diets of 6-8, 9-11, and 12-23 mo old breastfed children were quantified using 24-hour dietary recalls. Optifood, an automated linear programming tool, was used to identify recommended nutrient intakes (RNIs) that could not be achieved using locally available foods (problem nutrients) and optimal food-based recommendations that would improve dietary adequacy for 11 nutrients, if adopted. Model constraints ensured they conformed to local food patterns. Results: Problem nutrients were iron and zinc (all age/location subgroups), plus calcium in Vihiga and vitamin B12 in 12-23 mo olds in Kitui. Dietary vitamins A and C were adequate in most subgroups, while most B-vitamins were moderately inadequate in most subgroups. Specific recommendations varied somewhat by subgroup, but included increased weekly servings of green leafy vegetables, legumes, existing fortified cereals, dairy products, plus millet flour and meat, fish or egg in Kitui, and sardines in Vihiga. Conclusions: In conclusion, food-based recommendations alone can ensure >65% of RNIs for all nutrients, except for iron and zinc (all subgroups), and folate or niacin (12-23 mos), which require external solutions such as new targeted fortified foods. These results provide an evidence base for designing appropriate interventions for improved complementary diets.

The Prevalence of, and Factors Associated with Single and Multiple Deficiencies of Iron, Vitamin A and Zinc amongst Children Aged 12 – 35 Months in Colombia.

Objectives: Few national nutrition surveys have assessed the prevalence of single and multiple micronutrient deficiencies among young children, despite their potential negative impact on child health, growth and development. This study aimed to investigate the prevalence of iron, zinc and vitamin A deficiency among Colombian children aged 12 – 35 mo, and to explore associated socio-demographic factors. Methods: Data from the 2005 Colombian National Nutrition Survey (ENSIN) were used to investigate the prevalence of single and concurrent low biochemical status for iron (plasma ferritin <12.0 mg/L), zinc (serum zinc < 9.2 µmol/L), and vitamin A (serum retinol < 20 µg/dL) (n=2740). Logistic regression was performed to investigate socio-demographic factors associated with single and multiple micronutrient deficiencies. Results: The prevalence of single micronutrient deficiencies amongst 12 – 23 and 24 - 35 mo children, respectively, were 26.4% (95% CI 23.8%, 29.4%) and 16.7% (95% CI 14.4%, 19.1%) for low serum ferritin, 30.2% (95% CI 28.7%, 31.7%) and 24.6% (95% CI 23.2%, 26.0%) for low serum zinc and 6.7% (95% CI 5.9%, 7.5%) and 5.4% (95% CI 4.7%, 6.1%) for low serum retinol. Overall, 12.2% (95% CI 11.3%, 13.1%) of children aged 12 – 23 mo and 5.4% (95% CI 4.8%, 6.0%) of children aged 24 – 35 mo had 2 or more deficient biomarkers. Factors significantly associated with single or multiple deficiencies were age-group (12 – 23 mo > 24 - 35 mo) and region, with children in Atlántica being at highest risk. Conclusions: Future interventions should regionally target children aged 12 – 23 mo.